Orthopaedic plate and screw assembly

ABSTRACT

Systems, devices and methods are disclosed for treating fractures and other bone maladies. The systems, devices and methods may include one or both of a stabilizing structure, such as an implant, bone plate, or other device and a fastening assembly, such as an engaging member and a compression member. The stabilizing structure in some embodiments has a proximal section with a transverse aperture and a cross-section that may be shaped to more accurately conform to the anatomical shape of cortical bone and to provide additional strength and robustness in its lateral portions, preferably without requiring significant additional material. The fastening assembly may be received to slide, in a controlled way, in the transverse aperture of the stabilizing structure. In some embodiments, the engaging member and the compression member are configured so that the compression member interacts at least indirectly with the stabilizing structure and a portion of the engaging member to enable controlled movement between the first and second bone fragments. This configuration is useful for, among other things, compressing a fracture.

RELATED APPLICATIONS

This application is a continuation-in-part of U.S. application Ser. No. 11/725,872, entitled “Orthopaedic Plate and Screw Assembly,” filed on Mar. 20, 2007, and is also a continuation-in-part of U.S. application Ser. No. 11/725,677, also entitled “Orthopaedic Plate and Screw Assembly” and filed on Mar. 20, 2007, now U.S. Pat. No. 7,780,667 the entire contents of both of which are incorporated by this reference.

RELATED FIELDS

Embodiments of the present invention generally relate to systems for coupling bone portions across a fracture and, more specifically, to intramedullary nail or plate and screw assemblies or other stabilizing structures and fastening assemblies used to treat fractures of long bones, such as the femur, humerus, tibia, and various periarticular fractures of these and other bones.

BACKGROUND

There are a variety of devices used to treat fractures of the femur, humerus, tibia, and other long bones. For example, fractures of the femoral neck, head, and intertrochanteric region have been successfully treated with a variety of compression screw assemblies, which include generally a compression plate having a barrel member, a lag screw and a compressing screw. Examples include the AMBI® and CLASSIC® compression hip screw systems offered by Smith & Nephew, Inc. In such systems, the compression plate is secured to the exterior of the femur, and the barrel member is inserted in a predrilled hole in the direction of the femoral head. The lag screw has a threaded end, or another mechanism for engaging bone, and a smooth portion. The lag screw is inserted through the barrel member so that it extends across the break and into the femoral head. The threaded portion engages the femoral head. The compression screw connects the lag screw to the plate. By adjusting the tension of the compression screw, the compression (reduction) of the fracture can be varied. The smooth portion of the lag screw is free to slide through the barrel member to permit the adjustment of the compression screw. Some assemblies of the prior art use multiple screws to prevent rotation of the lag screw relative to the compression plate and barrel member and also to prevent rotation of the femoral head on the lag screw.

Intramedullary nails in combination with lag screws or other screw assemblies have been successfully used to treat fractures of the femur, humerus, tibia, and other long bones as well. A significant application of such devices has been the treatment of femoral fractures. One such nailing system is the IMHS® system offered by Smith & Nephew, Inc., and covered at least in part by U.S. Pat. No. 5,032,125 and various related international patents. Other seminal patents in the field include U.S. Pat. Nos. 4,827,917, 5,167,663, 5,312,406, and 5,562,666, which are all assigned to Smith & Nephew, Inc. A typical prior art intramedullary nail may have one or more transverse apertures through its distal end to allow distal bone screws or pins to be screwed or otherwise inserted through the femur at the distal end of the intramedullary nail. This is called “locking” and secures the distal end of the intramedullary nail to the femur. In addition, a typical intramedullary nail may have one or more apertures through its proximal end to allow a lag screw assembly to be screwed or otherwise inserted through the proximal end of the intramedullary nail and into the femur. The lag screw is positioned across the break in the femur and an end portion of the lag screw engages the femoral head. An intramedullary nail can also be used to treat shaft fractures of the femur or other long bones.

As with compression hip screw systems, intramedullary nail systems are sometimes designed to allow compression screws and/or lag screws to slide through the nail and thus permit contact between or among the bone fragments. Contact resulting from sliding compression facilitates faster healing in some circumstances. In some systems, two separate screws (or one screw and a separate pin) are used in order, among other things, to prevent rotation of the femoral head relative to the remainder of the femur, to prevent penetration of a single screw beyond the femoral head, and to prevent a single screw from tearing through the femoral neck and head. When an additional screw or pin is used, however, unequal forces applied to the separated screws or pins can cause the separate screws or pins to be pressed against the sides of the holes through which the separate screws or pins are intended to slide. This may result in binding, which reduces the sliding of the screws or pins through the nail.

Additionally, problems may result from weakened, soft, or poor quality bone that is adjacent to the fracture site. Oftentimes the bone adjacent to the fracture is weak and is prone to damage when exposed to compression. For example, there could be excessive compression of the femoral head when the femoral head compresses towards or into the fracture site. In extreme cases, excessive compression may cause the femoral head to be compressed all the way into the trochanteric region of the femur. In this situation, it might be beneficial to stop or otherwise limit the distance that the femoral head is free to move in the lateral direction towards the trochanteric region of the femur. Limiting the movement in this manner helps to prohibit excessive compression of the weak bone adjacent to the fracture cite.

The harder, generally outer portion of a typical bone is referred to as cortical bone. Cortical bone is usually a structurally sound load-bearing material for support of an implant. A cross-section of a long bone that shows the typical anatomical shape of cortical bone generally reveals a non-circular ring of cortical bone which surrounds a medullary canal. Accordingly, the medullary canal generally features a non-circular cross section. Intramedullary nails of the prior art, however, are usually round or square in cross-section, and therefore not anatomically consistent with the cortical bone or the medullary canal. Some have addressed this problem by reaming the medullary canal of the bone with a round reamer in order to cause the nail to fit the cortical bone. This approach, however, can remove significant portions of healthy cortical bone.

The problem of providing an effective load bearing physical relationship between an implant and cortical bone in the proximal femur has been addressed in the art of hip replacement devices. Various hip stems have been developed which feature generally non-circular cross sections along their length, in order better to fit the anatomically shaped cortical bone of the proximal femur and thus more evenly and effectively distribute the load between the stem and the bone. However, none of these hip stem geometries have been incorporated into a nail, bone plate, or other implant or stabilizing structure, nor have they been configured to accept a screw or screws useful in repairing substantially all of the portions of the treated bone. Instead, hip stems as a general matter have been considered as a device for replacing portions of a long bone, and designed and used for that purpose. For example, the typical application of a hip stem includes completely removing a femoral head and neck, implanting a hip stem, and using the hip stem to support an artificial femoral head.

Sometimes it is desirable to attach an attachment, such as, but not limited to, a handle, drill guide or other instrumentation, to an implant such as a stabilizing structure or intramedullary nail. With some previous devices, it has been difficult to connect an attachment to the implant once that implant has been inserted into the patient, especially if the implant has already been attached to, inserted in or otherwise associated with the patient's bony anatomy. With some such devices, if it was desired to utilize an attachment with the implant at some point during the procedure, it would have been necessary to connect at least a portion of that attachment to the implant prior to insertion of the implant into the body. Such an approach may be undesirable, as the surgeon might not know in advance that he/she would require an attachment during the procedure. If the surgeon realized in the middle of surgery that he/she required an attachment, the surgeon may have to take inconvenient steps to accommodate the attachment, or may have to remove the implant entirely and begin the procedure again.

SUMMARY

Methods, devices and systems according to certain aspects of this invention allow treatment of bone fractures and other types of maladies using one or both of a stabilizing structure for association with a first bone fragment and a fastening assembly for association with a second bone fragment. The stabilizing structure may be a plate or other device for at least partial application to the outer surface of bone, or an implant for at least partial implantation within bone. Such stabilizing structures may include a proximal section having a transverse aperture.

In some embodiments, one or more cross sections of the proximal section may feature shapes that impart additional strength and resistance to tension. Such shapes can be provided, for instance, by one or both (i) adding additional mass in lateral portions of the cross section, and (2) strategically adding and reducing mass in the cross section to take advantage of flange effects similar to the way flanges add structural benefits to I-beams and channels. One way to characterize such cross-sections, which can but need not be asymmetrical with respect to at least one axis, is that they generally feature a moment of inertia extending in a lateral direction from a point that is the midpoint of a line from a lateral tangent to a medial tangent of the cross section. In some structures, that line is coplanar with the axis of the transverse aperture and coplanar with the cross section and thus defined by the intersection of those planes. The endpoints of that line can be defined as the intersection of the line with tangents to the medial aspect and the lateral aspect of the cross section, respectively. In some embodiments, such stabilizing structures may also include a transition section to provide a coupling between proximal and distal sections of the stabilizing structure. In other embodiments, it is not necessary that the stabilizing structure include these geometries and/or properties.

Fastening assemblies of methods, devices and systems according to certain embodiments of the invention may at least partially extend through the transverse aperture of the stabilizing structure and may include an engaging member and a compression member. The engaging member may be a lag screw or other similar device used to gain purchase in or otherwise engage a second bone fragment. The engaging member may be able to slide with respect to the transverse aperture of the stabilizing structure. The engaging and compression members may be configured such that the compression member at least indirectly interacts with a portion of the stabilizing structure as well as a portion of the engaging member to enable controlled movement between the first and second bone fragments. In some embodiments, the compression member at least partially directly contacts the second bone fragment.

In some embodiments, methods, devices, and systems of the present invention include an barrel received in the stabilizing structure's transverse aperture that includes another transverse aperture. In such embodiments, the fastening assembly may at least partially extend through the second transverse aperture.

BRIEF DESCRIPTION OF DRAWINGS

FIG. 1 is a perspective view of an intramedullary nail according to one embodiment of the present invention shown installed in a femur.

FIG. 1A is a perspective view of an intramedullary nail according to one embodiment of the present invention, shown in greater detail than the intramedullary nail shown in FIG. 1.

FIG. 1B is a perspective view of an intramedullary nail according to another embodiment of the present invention.

FIG. 1C is a cross-sectional view of a portion of the nail of FIG. 1B.

FIG. 1D is a perspective view of an intramedullary nail according to another embodiment of the present invention.

FIG. 2 is an elevation view of the intramedullary nail of FIG. 1.

FIG. 3 is a cross-section view of the intramedullary nail of FIG. 2 taken through the line 3-3.

FIG. 4 is a side view of the intramedullary nail of FIG. 2.

FIG. 5 is a cross-section view of the intramedullary nail of FIG. 4 taken through the line 5-5.

FIG. 6 is a cross-section of the intramedullary nail of FIG. 4 taken through the line 6-6.

FIG. 7 is a perspective view of an intramedullary nail according to an alternative embodiment of the invention.

FIG. 8 is a perspective view of an intramedullary nail according to an alternative embodiment of the invention.

FIG. 9 is a perspective view of an intramedullary nail according to an alternative embodiment of the invention.

FIG. 10 is a perspective view of an intramedullary nail according to an alternative embodiment of the invention.

FIG. 11 is a perspective view of an intramedullary nail according to an alternative embodiment of the invention.

FIG. 12 is a perspective view of an intramedullary nail according to an alternative embodiment of the invention.

FIG. 13 is a cross-section view of the intramedullary nail of FIG. 7 taken through line 13-13.

FIG. 14 is a cross-section view of the intramedullary nail of FIG. 8 taken through line 14-14.

FIG. 15 is a cross-section view of the intramedullary nail of FIG. 9 taken through line 15-15.

FIG. 16 is a cross-section view of the intramedullary nail of FIG. 10 taken through line 16-16.

FIG. 17 is a cross-section view of the intramedullary nail of FIG. 11 taken through line 17-17.

FIG. 18 is a cross-section view of the intramedullary nail of FIG. 12 taken through line 18-18.

FIG. 19 is a perspective view of a tool according to an embodiment of the present invention for preparing bone to receive certain devices according to certain embodiments of the present invention.

FIG. 20 is a perspective view of a device which includes a version of a fastener assembly according to one embodiment of the present invention.

FIG. 21 is an exploded view of the intramedullary device and fastener assembly shown in FIG. 20.

FIG. 22 is a perspective view of the fastener assembly shown in FIG. 20.

FIG. 23 is an exploded view of the fastener assembly of FIG. 20.

FIG. 24 is an elevation view of the engaging member of the fastener assembly of FIG. 23.

FIG. 25 is a side view of the engaging member of FIG. 24.

FIG. 26 is a cross-section view of the engaging member of FIG. 24 taken through line 26-26.

FIG. 27 is an end view of one end of the engaging member of FIG. 24

FIG. 28 is an end view of the other end of the engaging member of FIG. 24.

FIG. 29 is an elevation view of the compression device of the fastener assembly of FIG. 22.

FIG. 30 is a cross-section view of the compression device of FIG. 29 shown through line 30-30.

FIG. 31 is an end view of one end of the compression device of FIG. 29.

FIG. 32 is an end view of the other end of the compression device of FIG. 29.

FIG. 33 is a cross-section view of an intramedullary nail and screw assembly according to another embodiment of the present invention.

FIG. 34 is a perspective view of a fastener assembly according to another embodiment of the invention.

FIG. 35 is a perspective view of the lag screw of the fastener assembly of FIG. 34.

FIG. 36 is a perspective view of a fastener assembly according to another embodiment of the invention.

FIG. 37 is a perspective view of the lag screw of the fastener assembly of FIG. 36.

FIG. 38 is a perspective view of a fastener assembly according to another embodiment of the invention.

FIG. 39 is an exploded view of the fastener assembly of FIG. 38.

FIG. 40 is a perspective view of a fastener assembly according to another embodiment of the invention.

FIG. 41 is an exploded view of the fastener assembly of FIG. 40.

FIG. 42 is a perspective view of a compression plate according to an embodiment of the present invention which includes a fastener assembly according to an embodiment of the invention.

FIG. 43 is a perspective view of a periarticular plate according to an embodiment of the present invention which includes a fastener assembly according to an embodiment of the invention.

FIG. 44 is a perspective view of a device according to an embodiment of the present invention used in the context of humeral repair in a shoulder joint.

FIG. 45 is a perspective view of a stabilizing structure according to another embodiment of the present invention.

FIG. 46 is a perspective view of a barrel that may be used in conjunction with the stabilizing structure shown in FIG. 45.

FIG. 47A is a side view of an apparatus for treating bone maladies according to another embodiment of the present invention.

FIG. 47B is a side view of an apparatus for treating bone maladies according to another embodiment of the present invention.

FIGS. 48-60 show various instruments and illustrate various methodologies that may, in some embodiments, be used to install apparatuses according to some embodiments of the present invention.

FIG. 61 is an exploded view of an apparatus for treating bone maladies according to another embodiment of the present invention, wherein the apparatus includes and an adjustable stop.

FIG. 62 shows a perspective view of a portion of the apparatus shown in FIG. 61, shown without the adjustable stop.

FIG. 63 shows a perspective view of a portion of the apparatus shown in FIG. 61, shown with the adjustable stop.

FIG. 64 shows one embodiment of an adjustable stop.

FIGS. 65-81 show various examples of other types of adjustable stops and stabilizing structures for use with those adjustable stops.

FIGS. 82A-82C show cross-sectional views of an apparatus for treating bone maladies according to another embodiment of the present invention that includes an embodiment of an adjustable stop.

FIG. 83 shows a perspective view of a portion of an apparatus for treating bone maladies according to some embodiments of the present invention.

FIG. 84 shows a side view of the apparatus in FIG. 83 wherein an attachment is attached to the apparatus.

FIG. 85 shows another partial view of the apparatus of FIG. 83.

FIG. 86 shows a perspective view of one example of an attachment that may be used with an apparatus for treating bone maladies according to some embodiments of the present invention.

FIG. 87 shows a series of perspective views of the apparatus in FIG. 83 wherein an attachment is attached to the apparatus.

FIG. 88 shows a side view of an engaging member according to some embodiments of the invention.

FIG. 89 shows a sectional view of the engaging member in FIG. 88.

FIG. 90 shows an end view of a barrel for use with the engaging member shown in FIGS. 88-89 according to some embodiments of the invention.

DETAILED DESCRIPTION OF DRAWINGS

Methods, devices and systems according to embodiments of this invention may seek to provide improved treatment of femur fractures and other types of maladies of the femur and other bones. FIGS. 1-6 illustrate various views of one embodiment of an intramedullary nail 100 of the present invention. The intramedullary nail 100 has a longitudinal bore 130 throughout to aid in insertion in the bone. The intramedullary nail 100 has a proximal section 102, a transition section 104 and a distal section 106.

In some embodiments, the proximal section 102 of the particular structure shown in FIGS. 1-6 may feature an anatomically inspired shape that corresponds more accurately to typical cortical bone. One version of such shape is shown in the cross-sectional view of the proximal section 102 in FIG. 6. The particular cross-section of the proximal section 102 shown in FIG. 6 is generally non-circular along at least some portions of its length, and has a lateral side or aspect 108 that is larger than a medial side or aspect 109. The lateral side 108 and medial side 109 are joined by a first side 110 and a second side 116. At the intersection of the first side 110 with the lateral side 108 is a first radiused corner 112 and at the intersection of the second side 116 with the lateral side 108 is a second radiused corner 114. The first side 110, second side 116 and lateral side 108 are of approximately equal length. The first side 110 and second side 116 are oriented at acute angles relative to the lateral side 108, so that the medial side 109 is smaller than the lateral side 108. By having the lateral side 108 larger than the medial side 109 the rotational stability of the intramedullary nail 100 is increased, and resistance to bending and twisting can also be enhanced.

The medial side 109 shown in FIG. 6 can be radiused. As can be seen in FIG. 4, the radiused medial side 109 protrudes out from the transition section 104 and continues to the proximal end of the intramedullary nail 100. The protrusion of the medial side 109 corresponds to the calcar region of the femur and improves the evenness of load distribution between the bone and intramedullary nail 100.

Furthermore, the general cross-section geometry of the proximal section reduces peak stresses in the proximal section. More specifically, the typical failure mode of an intramedullary nail and screw assembly combination is failure of the nail in tension on its lateral side. The tension is created by bending moment induced by body weight load that is applied to the screw assembly. Therefore, it would be beneficial in reducing stress in the proximal section of a nail to include more material on the side of the nail that is in tension, the lateral side, to shape the cross section more effectively to enhance strength and robustness in the lateral area, or both. The design illustrated in FIG. 6 accomplishes this. The lateral side 108 is wider than the medial side 109, thus imparting, at least partially, a flange-like effect. Stress per unit area induced in the material on the lateral side 108 is less than would be the case if the lateral side featured a smaller cross-sectional area, such as medial side 109.

A structure according to another embodiment of the invention that benefits from the same principle is shown in FIGS. 1B and 1C, which illustrate an intramedullary nail 1100 with a generally circular cross section whose generally circular aperture 1128 is disposed other than concentric with the periphery of the cross section. In the particular structure shown in these two Figures, the offset aperture 1128 is offset toward the medial side 1109 such that a greater portion of material is available to take load, and reduce stress, on the lateral side 1108. Likewise, any cross-section that provides more material on the lateral side of the section reduces stress per unit area in the nail on that side.

Regardless of the particular manner in which material or mass may be added to some portions of the lateral parts of the cross section of proximal portion 102, material may be added and removed from some portions of the cross section in order to increase the strength and robustness of the lateral parts, or both, the effect can be characterized as imparting a moment of inertia to the cross section oriented at least partially in the direction of the lateral side or aspect 108. In some embodiments, the moment of inertia (shown denoted by the letter M on FIG. 6) can be characterized as extending in a lateral direction, or at least partially toward lateral aspect or side 108 from a point P that is the midpoint of a line L extending from the intersection I1 of that line with a tangent T1 to the lateral aspect 108, to the intersection I2 of that line with a tangent T2 to the medial aspect 109. Stated another way, the effect in at least some cases is to create a cross section that features a moment of inertia extending in an at least partially lateral direction from a center of the cross section. Preferably, that center can be a midpoint between the lateral and medial edges of the cross section. Alternatively, that center can be the center of mass of the cross section. The radius of gyration reflected by the moment of inertia, which is a function of the square of the distance of the incremental mass from the center, reflects additional strength in lateral parts of the proximal portion 102 caused by more mass or more strategically placed mass in the cross section. In some structures, line L is coplanar with the axis of the transverse aperture and coplanar with the cross section and thus defined by the intersection of those planes. As FIGS. 1A on the one hand, and 1B and 1C on the other hand, reflect, and bearing in mind that these are only three of a myriad of structures that can impart such lateral additional strength and robustness, the cross section can but need not be asymmetrical with respect to at least one of its axes. Additionally, the longitudinal opening 130 can be located to share its central axis with that of the cross section, or it can be offset in order to help impart the lateral strength or for other purposes.

In the particular devices shown in FIGS. 1, 1A, and 2-6, the first side 110, second side 116 and lateral side 108 are flat. Alternatively, these sides could be radiused or otherwise not flat. In the embodiments shown in FIGS. 1-6, the medial side 109 is radiused, but as one skilled in the art could appreciate, the medial side could be flat.

The proximal section 102 shown in FIG. 1A has a transverse aperture 118 that receives a fastening assembly 200 (various versions of which are shown in FIGS. 20-41) through the intramedullary nail 100. One embodiment of the proximal transverse aperture 118, shown in FIGS. 1-4, is formed from two overlapping circular apertures 120, 122, where the proximal circle aperture 120 is smaller in diameter than the distal circle aperture 122. The proximal circle aperture 120 shown has a shoulder 132 for constraining the insertion depth of the fastening assembly as will be explained in more detail below. Various other apertures allowing insertion of various fastening assemblies could be used as would be known to those skilled in the art. For example, FIG. 33 illustrates the intramedullary nail with a circular aperture. The embodiment of FIG. 33 is described in greater detail below.

The proximal section illustrated in FIG. 3 has a proximal end aperture 128. The proximal end aperture 128 is threaded to allow for the insertion of a set screw that can be used to fix the rotational and sliding position of a fastening assembly. A set screw may also include mechanisms for spanning a compression member 204 and interfering with an engaging member 204 to independently restrict the rotation or sliding of the engaging member 204.

As shown in FIGS. 1-6, the transition section 104 is tapered from the proximal section 102 to the distal section 106. The tapered nature of the transition section 104 creates a press fit in the intramedullary canal that controls subsidence. The tapered transition section 104 assists in preventing the nail 100 from being pressed further down into the intramedullary canal of the femur than intended.

In the intramedullary nail 100 embodiments shown in FIGS. 1-6, the cross-section of the transition section 104 is circular, but the cross-section could vary as known to those skilled in the art. The cross-section could be anatomically derived, similar to the cross-section of the proximal section 102, oval or non-circular. In the embodiment shown in FIGS. 1-6, the transition section 104 contains a distal transverse aperture 124. The distal aperture 124 allows the insertion through the intramedullary nail 100 of a distal locking screw for locking of the intramedullary nail 100.

The distal section 106 of the intramedullary nail 100 is generally cylindrical and is configured to provide a reduced bending stiffness. The embodiments shown in FIGS. 1-5 include a longitudinal slot 126 through the center of the distal section 106 that forms two sides 134, 136. The slot reduces bending stiffness at the distal end of the intramedullary nail 100 and reduces the chances of periprosthetic fractures.

FIG. 1D shows an intramedullary nail 100 according to another embodiment of the invention. This nail features, in its proximal portions, a noncircular cross section that is symmetrical with respect to its lateral-medial axis (in this case, preferably but not necessarily, oval shaped in cross-section), and which features a centered longitudinal bore (in this case, preferably but not necessarily, circular in cross-section). This nail achieves additional stability to the extent it resists twisting in the medullary canal. It also accomplishes the aim of placing more mass toward the lateral edge or aspect of the proximal cross section. Furthermore, it places additional mass toward the medial edge or aspect, and thus provides additional structure that acts as a fulcrum to decrease the mechanical advantage of the fastening assembly which when loaded is the component that imposes tensional stress on the lateral edge or aspect.

FIGS. 7-18 illustrate intramedullary nails 100 according to other embodiments of the invention. FIG. 7 illustrates an intramedullary nail 100 having no longitudinal bore throughout.

FIGS. 8 and 14 illustrate an intramedullary nail 100 having stiffness reduction slots 140 in the transition section 104 and the distal section 106. The stiffness reduction slots 140 reduce the bending stiffness at the distal end of the intramedullary nail 100 and could be used to receive locking screws in some embodiments.

FIGS. 9 and 15 illustrate an intramedullary nail 100 having three longitudinal slots 138 in the distal section 106 and a portion of the transition section 104 forming a cloverleaf pattern. This pattern more readily permits blood flow near the intramedullary nail 100 and also reduces bending stiffness at the distal end of the nail 100.

FIGS. 10 and 16 illustrate an intramedullary nail 100 in which the distal section 106 and a portion of the transition section 104 have a series of longitudinal grooves 146. The longitudinal grooves 146 reduce bending stiffness at the distal end, provide rotational resistance, and enhance blood flow near the intramedullary nail 100.

FIGS. 11 and 17 illustrate an intramedullary nail 100 where the transition section 104 and the distal section 106 have fins 144. The fins 144 provide rotational resistance for the intramedullary nail 100.

FIGS. 12 and 18 illustrate an intramedullary nail 100 having barbs 142 located on the distal section 106 and a portion of the transition section 104. The barbs 142 provide rotational resistance for the intramedullary nail 100.

Intramedullary nails according to some embodiments of the present invention may be inserted into a patient by any suitable known technique. Generally, the intramedullary canal of the bone is prepared with an appropriate tool to create a void for insertion of the nail. Some portions of the void may be prepared to be about 1 millimeter larger than the perimeter of the nail to permit sufficient space for blood flow after insertion of the nail. A guide pin or wire is optionally inserted into the prepared medullary canal. The nail is then introduced into the desired position. If the nail is cannulated, the nail can be introduced over the guide wire. The position of the nail may be confirmed by image intensification.

FIG. 19 shows one embodiment of a tool 300 for preparing a medullary canal. The tool has a drill bit 302 for reaming and also a mortise chisel 304. In operation, the drill bit 302 reams out the medullary canal of the femur and the mortise chisel 304 cuts out a larger section in the more proximal end of a bone. As shown in FIG. 19, the mortise chisel 304 has an anatomically derived cross-section of approximately the same shape as the proximal section of the intramedullary nail. By applying this type of shaped, mortise chisel, the proximal end of the nail will be better enabled to seat on cortical bone that has been only minimally altered. The mortise chisel 304 may be of a wide variety of shapes, even complicated, asymmetrical shapes. This is advantageous because it enables a device and method for preparing voids able to accept a wide variety of shapes of intramedullary nails without merely over-reaming circular voids. Preparation of an accurately conforming void is valuable in avoiding unnecessary removal of healthy bone, and in ensuring stable seating of the nail.

In operation, the tool 300 of the embodiment shown is advanced as a unit, with the drill bit 302 reaming and the mortise chisel 304 cutting simultaneously. The drill bit 302 may be turned with a power driver, or by hand. Likewise, the entire tool 300 may be advanced into a medullary canal manually, or advanced with the assistance of mechanical advantage or power equipment. In other configurations, the drill bit 302 may be cannulated (not shown) such that the entire tool 300 is operable over and guided by a guide wire that has been inserted into the medullary canal.

In other embodiments, the bit for reaming is a more traditional reamer that is separate from a cutting tool such as the mortise chisel 304. The method for preparing a void in such an instance would include first reaming an opening with a traditional reamer. A device such as a chisel or a broach, shaped similar to the intramedullary nail to be implanted, would then be used to prepare the void. The chisel or broach may be driven in by hand, with the assistance of a hammer or mallet, or with the use of other power equipment. A nail consistent with the void prepared would then be implanted.

Other custom instruments such as a contoured broach or a custom router bit and template could be used as well. Broaches have long been used to prepare openings for hip stems, and the use of a broach would be familiar to one of skill in the art. A router bit and template could be use, in effect, to mill out the desired shape in the bone. Such a method might also be used in combination with reaming or broaching to create the desired void.

Intramedullary nails in accordance with some of the embodiments of the present invention may be used to treat proximal femoral fractures and femoral shaft fractures, among other fractures of long bones and other bone maladies. When used to treat femoral shaft fractures, the intramedullary nail is secured in the femur by one or more fastening devices. When used for the treatment of proximal femoral fractures the intramedullary nail is preferably used in conjunction with a fastening assembly, such as the fastening assemblies described further below.

FIGS. 20 and 21 illustrate an intramedullary nail 100 according to one embodiment of the present invention used in conjunction with a fastening assembly 200 according to one embodiment of the present invention. This type of fastening assembly may be used in a variety of bones and to treat a number of indications, but for the purpose of providing an example, it is being described here in use with the proximal femur. In general, the fastening assembly is useful in any situation where one fragment of a bone is to be drawn back toward or pushed away from another fragment of the bone in a controlled manner. The fastening assembly provides the additional advantage of being configurable to allow sliding of the assembly in a desired direction after the movement of the bone fragments has been accomplished.

In the embodiment of FIG. 21, the axis of the proximal transverse aperture 118 in the intramedullary nail 100 is angled relative to the proximal section 102 and in use, is directed towards the femoral head. In this embodiment of the fastener assembly 200, an engaging member such as a lag screw 202 is used in conjunction with a compression member, such as a compression screw 204 or a compression peg. The screws are configured such that when in use the circumference of the lag screw 202 partially intersects with the circumference of the compression screw 204, so that the compression screw 204 nests partially within the circumference of the lag screw 202. This particular combination of lag screw 202 and compression screw 204 are further illustrated in FIGS. 22 through 32. Briefly, the lag screw 202 shown in these figures is intended to engage the femoral head and to slide in the transverse aperture 118 of the nail 100. The compression screw 204 engages a shoulder or other structure in transverse aperture 118 and also threads in the portion of lag screw 202 within which compression screw 204 nests, so that rotation of compression screw 204 controls sliding of the lag screw 202 relative to the nail 100 and thus compression of the femoral head against the fracture site.

The lag screw 202 shown in these drawings includes an elongate body 206 and threaded end 208. As shown in FIGS. 24 and 25, the threaded end 208 does not include a sharp end, which reduces the possibility of cut out through the femoral head. The elongate body 206 includes a channel 212 that allows for the positioning of the compression screw 204 partially inside the circumference of the lag screw 202. The channel 212 includes a threaded portion 210 that compliments and cooperates with a threaded section 214 of the compression screw 204. The compression screw 204 includes a threaded section 214 and a head section 215. The threaded section 214 of the compression screw 204 is configured such that the threads are relatively flat and smooth at the exterior surface so that they can easily slide in the aperture and also reduce the possibility of cut out.

The lag screw 202 is received in the proximal transverse aperture 118 and into a pre-drilled hole in the femur so that the lag screw 202 extends across the break and into the femoral head. The threaded end 208 of the lag screw 202 engages the femoral head as the lag screw 202 is rotated within aperture 118, causing its threaded end 208 to engage the femoral head. The threaded end 208 may be any device for obtaining purchase in the femoral head, and includes, but is not limited to, threads of any desired configuration including helices, barbs, blades, hooks, expanding devices, and the like. The placement depth of the lag screw 202 into the femoral head differs depending on the desired compression of the fracture.

The compression screw 204 can also be received through the proximal transverse aperture 118 into a predrilled hole in the femoral head. The threaded section 214 of the compression screw 204 engages with the threaded portion of the channel 212 of the lag screw 202. The proximal transverse aperture 118 has an interior shoulder 132 (FIG. 21) to limit the sliding of the compression screw 204 in the general medial direction and, therefore, the lag screw 202, through the aperture 118. When the compression screw 204 is tightened, the compression screw threads 214 engage with the lag screw channel threaded portion 210 and the compression screw 204 moves in the generally medial direction down the lag screw 202. The head section 215 of the compression screw 204 engages the shoulder 132 of the proximal transverse aperture 118 preventing the compression screw 204 from moving further in the general medial direction. As the compression screw 204 is tightened, the lag screw 202 is drawn in the general lateral direction toward the intramedullary nail compressing the fracture. The compression screw 204 partially intersecting the circumference of the lag screw 202 provides greater surface resistance and aids in the prevention of femoral head rotation. The compression screw 204 therefore acts not only as a part of the mechanism for moving fragments of the fractured bone relative to one another, but also directly contacts bone of the femoral head to help prevent the femoral head from rotating about the axis of the lag screw 202. In other embodiments, it is not necessary to use the compression screw 204 (which may also be referred to as a compression member as discussed below) to compress the fracture, and the fracture may be stabilized simply by installing the compression screw 204 and lag screw 202 (which may also be referred to as an engagement member as discussed below).

In one embodiment, a set screw (not shown), positioned in the proximal end aperture 128 of the intramedullary nail, is used to engage the compression screw 204 and fix the compression screw 204 and lag screw 202 in place. The use of the set screw to fix the fastener assembly 200 in place may be fracture pattern dependent. If a set screw is not used to engage the fastener assembly, in some embodiments, the fastener assembly 200 can slide within the proximal aperture limited by the shoulder 132.

In the embodiment of the lag screw and compression screw shown in FIGS. 20-32, the diameter of the compression screw 204 is smaller than the diameter of the lag screw 202. In other embodiments, the diameters of the lag screw and compression screw could be the same or the diameter of the lag screw could be smaller than the diameter of the compression screw. The threads of the lag screw and the compression screw could be a variety of different shapes as known to those skilled in the art. In general, the purpose of the lag screw is to obtain purchase in bone, and the purpose of the compression screw is to engage with and draw or move the lag screw. Any configuration that permits these functions is within the scope of the invention.

The fastener assembly 200 shown in the Figures could additionally be configured to allow the addition of a prosthetic femoral head and neck. In such an embodiment, the lag screw 202 would be replaced with a prosthetic head and neck. The neck would fit into the proximal transverse aperture 118 in the nail 100. The design would be beneficial where degeneration or re-injury of a repaired femoral fracture and hip joint later necessitated a total hip arthroplasty (THA). The decision to accomplish a THA could be made interoperatively, or after some period of time. Instead of having to prepare a femur to accept a hip stem as is known in association with THA, only a small portion of bone would need to be removed, along with the fastener assembly 200. The prosthetic head and neck could then be inserted into the proximal transverse aperture 118, the acetabulum prepared, and the remainder of the THA completed.

FIG. 33 is a cross-section view of an intramedullary nail 100 according to another embodiment of the invention with an alternate fastener assembly 400. The fastener assembly illustrated is very similar to the compressing fastener assembly of Smith & Nephew's IMHS® system, as is more thoroughly disclosed in U.S. Pat. No. 5,032,125 and various related international patents. The improvement of the device illustrated is that it includes the intramedullary nail 100 with an anatomically derived shape and its multiple advantages as discussed above. In operation, a sleeve 401 fits through the intramedullary nail 100, and may be secured to the nail by set screw, or other effective mechanisms. A sliding lag screw 402 is able to move axially within the sleeve 401. A compressing screw 404 is threaded into the sliding lag screw 402 such that tightening of the compressing screw 404 draws the sliding lag screw 402 back into the sleeve 401. With this mechanism, a bone fragment may be brought into a desired position, but still permitted to achieve sliding compression once positioned.

FIGS. 34-35 illustrate a fastener assembly 200 according to another embodiment of the invention having a lag screw 202 and a compression peg 502. As shown in FIG. 34, the lag screw 202 and the compression peg 502 are configured such that, when in use, the circumference of the lag screw 202 partially intersects with the circumference of the compression peg 502, although in some embodiments the circumferences might be adjacent rather than intersecting. The lag screw 202 includes an elongate body 206 and threaded end 208. The lag screw 202 has a key 504 on the channel 212. The compression peg 502 has a slot 503 that is adapted to receive the key 504 of the lag screw 202. The key 504 and slot 503 can be a variety of complimentary shapes, such as, when considered in cross section, triangular, D-shaped, key-holed and other shapes as are apparent to those skilled in the art. In operation, the compression peg 502 may be moved relative to the lag screw 202 by a compression tool (not shown) that applies disparate forces between the compression peg 502 and the lag screw 202, or between the entire assembly and the intramedullary nail 100.

In the fastener assembly 200 shown in FIGS. 34-35, the lag screw 202 is received to slide in a proximal aperture of the intramedullary nail so that the lag screw 202 extends across the break and into the femoral head. The threaded end 208 of the lag screw 202 engages the femoral head. Once the lag screw 200 has been properly engaged with the femoral head, the compression peg 502 is inserted in the proximal aperture into a predrilled hole in the femoral head, in order to prevent further rotation of the lag screw 202 as the slot 503 of the compression peg 502 receives the key 504 of the lag screw 202. By providing more area for resistance, the compression peg 502 helps to prevent the rotation of the femoral head on the lag screw 202. The compression peg 502 is fixed in position in the intramedullary nail 100 by a set screw positioned in the proximal end aperture of the nail. The lag screw 202 can slide on the compression peg 502 through the proximal aperture. In another embodiment, the compression peg 502 has barbs on its surface.

A fastener assembly 200 according to another embodiment of the invention is illustrated in FIGS. 36-37. The fastener assembly 200 of this embodiment has a compression peg 502 and a lag screw 202 similar to the embodiment illustrated in FIGS. 34-35, except that the key 504 of the lag screw 202 and the slot 503 of the compression peg 502 have complimentary ratchet teeth 506. The compression peg 502 is fixed in position in the intramedullary nail by a set screw positioned in the proximal end aperture. Compression of the fracture can be achieved by pulling the lag screw in the general lateral direction. The ratchet teeth 506 allow the lag screw 202 to move in the general lateral direction, but prevent the lag screw 202 from moving in the general medial direction. A compression tool similar to the tool described in association with FIGS. 34-35 may be used to accomplish the movement.

FIGS. 38-39 show a fastener assembly 200 according to another embodiment of the invention having a lag screw 602, a cross hair screw 610 and a compression screw 604. The lag screw 602 includes an elongate body 606 and threaded end 608. The elongate body 606 is semi-circular shaped in cross section. The screws 602, 604, 610 are configured so that the circumference of the lag screw 602 intersects with the circumferences of the cross hair screw 610 and the compression screw 604. The elongate body 606 of the lag screw 602 is threaded to compliment and cooperate with a threaded section 602 of the cross hair screw 610. The cross hair screw 610 is threaded to engage with the lag screw 602 and the compression screw 604. The compression screw 604 includes a threaded portion 614 and a head portion 612.

In this embodiment, the lag screw 602, the cross hair screw 610 and the compression screw 604 are received simultaneously to slide in a proximal aperture of an intramedullary screw. The lag screw 602 extends across the break and into the femoral head. The threaded end 608 of the lag screw 602 engages the femoral head. As compression screw 604 is tightened, the threads 614 of the compression screw engage the threads of the cross hair screw 610 and lag screw 602, thereby moving the lag screw 602 in the general lateral direction toward the intramedullary nail providing compression to the femoral head. The cross hair screw 610 is then turned causing the compression screw 604 to move in the distal direction away from the lag screw 602. The fastener assembly 200 can alternatively be configured so that the compression screw 604 moves proximally relative to the lag screw 602. The compression screw 604 separates from the lag screw 602 to help to prevent rotation of the femoral head on the lag screw 602 by adding more area for resistance.

FIGS. 40-41 illustrate a fastener assembly 200 according to another embodiment of the invention having a lag screw 702 and a compression peg 704. The lag screw 702 includes an elongate body 706 and a threaded end 708. The elongate body 706 is semi-circular shaped in order to allow the compression peg 704 to be positioned partially inside the circumference of the lag screw 702 for insertion into the femur and has a key 712 positioned on the interior side of the elongate body 706. The elongate body 706 also has an aperture 710 through the body. The compression peg 704 is generally cylindrical and is sized to fit within the semi-circular body 706 of the lag screw. The key 712 of the lag screw is received by a slot 714 in the compression peg 704. The key 712 and slot 714 contain complimentary ratchet teeth (not shown).

In this embodiment, the lag screw 702 and the compression peg 704 are received simultaneously to slide in a proximal aperture of an intramedullary nail into a pre-drilled hole in the femur. The lag screw 702 extends across the break and into the femoral head. The threaded end of the lag screw 702 engages the femoral head. A compression tool similar to the tool describe in association with FIGS. 34-35 may be used to accomplish movement between the compression peg 704 and the lag screw 702, or between the entire assembly and the intramedullary nail 100. A set screw may used to fix the position of the fastener assembly. The set screw is configured such that when the set screw is tightened a protrusion on the set screw is received through the slot 710 of the lag screw 702 and moves the compression screw 704 away from the lag screw 702. The compression screw 704 separate from the lag screw 702 helps to prevent rotation of the femoral head on the lag screw by adding more area for resistance.

FIG. 42 illustrates another embodiment of the invention where a fastener assembly 200 is employed in cooperation with a compression plate 150. As illustrated, the devices are being applied to a femur. The various embodiments of the fastener assembly 200 disclosed above may be used with a similar compression plate, and various compression plates may be configured to be applicable to other parts of the anatomy.

FIG. 43 illustrates another embodiment of the invention where a fastener assembly 200 is being used with a periarticular plate 170. The plate and fastener assembly shown are being applied to a proximal tibia. The various embodiments of the fastener assembly 200 disclosed above may be used with a similar periarticular plate and various periarticular plates may be configured to be applicable to other parts of the anatomy.

FIG. 44 illustrates another embodiment of the invention where a fastener assembly 200 is used in combination with a humeral nail 190. As illustrated, a head section 212 of compression screw 204 bears against the humerus to draw compression against the humerus. With the compression force applied to lag screw 202, and the lag screw 202 affixed to a bone fragment through its threaded end 208, the bone fragment may be drawn into position for proper healing. In some circumstances, it may be advantageous to place a washer or bearing surface (not shown) between the head section 212 and the humeral bone against which the head section 212 compresses. In yet another variant, the opening in the humerus may be enlarged such that head section 212 is permitted to penetrate the humerus and bear against a portion of the humeral nail 190. In such an embodiment, the fastener assembly 200 would be shorter than illustrated in FIG. 45 to obtain purchase in the same area of bone with the threaded end 208. The various embodiments of the fastener assembly 200 disclosed above may be used with a similar nail and various nails may be configured to be applicable to other parts of the anatomy.

FIGS. 45-60 show apparatuses 2000 for treating bone maladies in accordance with other embodiments of the present invention. The apparatuses 2000 shown in these figures generally include a stabilizing structure 2002 and a fastening assembly 2004. The stabilizing structure 2002 shown in FIG. 45 is a bone plate, however, in other embodiments, stabilizing structure 2002 may be other orthopaedic devices for at least partial application to the bony anatomy, such as the outer surface of a bone.

Similar to the intramedullary nails discussed above, the stabilizing structure 2002 may feature geometries that impart a moment of inertia to a cross section of the stabilizing structure 2002 oriented at least partially in the direction of a lateral side or aspect of the stabilizing structure 2002, to increase its strength and/or robustness. For instance, FIG. 45 shows a stabilizing structure 2002 in which the proximal portion has a lateral side with an increased mass to impart additional strength and resistance to tension. In other embodiments, however, such geometries are unnecessary and stabilizing structure 2002 may feature other traditional or non-traditional geometries.

The stabilizing structure 2002 shown in FIG. 45 includes a first transverse aperture 2006 and a number of additional apertures 2008. Transverse aperture 2006 extends through a proximal portion of stabilizing structure 2002, such that it can receive a fastening assembly 2004 and (optionally) a barrel 2010, as discussed further below. The transverse aperture 2006 shown in FIG. 45 extends through stabilizing structure 2002 at an angle, such that fastening assembly 2004 will roughly parallel a longitudinal axis of the femoral neck when the stabilizing structure 2002 is applied to the proximal femur in the manner shown in FIGS. 47A and 47B. In other embodiments, however, apparatus 2000 can be used to treat bone maladies associated with other parts of the bony anatomy, and transverse aperture 2006 does not necessarily extend through stabilizing structure 2002 at an angle.

The additional apertures 2008 shown in FIG. 45 may be used in conjunction with bone screws or other types of fastening or anchoring devices to secure the stabilizing structure 2002 to the bony anatomy. As discussed further below, one or more of the additional apertures 2008 may also be used to associate the stabilizing structure 2002 with various instrumentation used to install the apparatus 2000.

The transverse aperture 2006 of the stabilizing structures 2002 shown in FIG. 45 may receive a barrel 2010 that includes a second transverse aperture 2012, through which the fastening assembly 2004 may pass. One type of barrel 2010 is shown in FIG. 46 and includes an arm 2014 and a ridge member 2016 that can interact with indentions/grooves 2018 and 2020 in stabilizing structure 2002 to allow the barrel 2010 to be securely snapped into the transverse aperture 2006 in stabilizing structure 2002. In other embodiments, the arm 2014 and ridge member 2016 can extend from stabilizing structure 2002 and the indentions 2018 and 2020 can be located in barrel 2010. In some embodiments, ridge member 2016 may be a clip engaged with two apertures extending at least partially into barrel 2010, as shown in FIG. 46. In still other embodiments, other structures, devices, and mechanisms can be used to associate barrel 2010 with stabilizing structure 2002.

The barrel 2010 shown in FIG. 46 also includes a flange 2022 that can interact with one or more portions of the fastening assembly 2004 in a somewhat similar manner to the shoulder 132 discussed in conjunction with the intramedullary nails described above.

The second transverse aperture 2012 shown in FIG. 46 is formed from two overlapping circular apertures, where the distal circular aperture is smaller in diameter than the proximal aperture. In other embodiments, the proximal aperture's diameter may be smaller than the distal aperture's diameter, the apertures may have the same diameter, or the apertures may be formed in other, such as non-circular, shapes.

In some embodiments, the use of a modular barrel, such as the barrel 2010 shown in FIG. 46, may allow the apparatus 2000 to be installed into a patient using minimally or less invasive techniques, such as, but not limited to, the techniques described further below. For instance, in some embodiments, the use of stabilizing structure 2002 in conjunction with a modular barrel 2010, where the stabilizing structure 2002 is installed first and the modular barrel 2010 is installed later, may reduce the size of the incision necessary for installation of the apparatus 2000.

In these or other embodiments, use of a modular barrel 2010 in conjunction with stabilizing structure 2002 may also facilitate an accurate installation of apparatus 2000. For instance, in some embodiments, stabilizing structure 2002 may be installed prior to certain bone preparation operations, such as drilling cavities necessary for receiving fastening assembly 2004 and/or barrel 2010. In such embodiments, the stabilizing structure 2002 may be used to reference and locate various bone preparation operations to facilitate drilling cavities and performing other bone preparation operations accurately with respect to the already installed stabilizing structure 2002.

Embodiments of the invention are not limited to barrels 2010 that are modular, however, because in some embodiments the barrel 2010 is integral with the stabilizing structure 2002. It should be understood that the word “barrel” is not limited to ones that are modular, but also include barrels that are integral with the stabilizing structure 2002.

The fastening assembly 2004 used in conjunction with apparatus 2000 shown in the figures includes an engaging member 2024 and a compression member 2026. The engaging member 2024 may be positioned above the compression member 2026 (shown in FIG. 47A), below the compression member 2026 (shown in FIG. 47B), or in some other arrangement. Engaging member 2024 can be used to engage a second bone portion, such as the femoral head shown in FIG. 47A. The compression member 2026 may contact and interact with the engaging member 2024 to facilitate a sliding movement of the engaging member 2024 with respect to the transverse apertures 2006 and/or 2012. The compression member 2026 may also at least indirectly interact with the stabilizing structure 2002 to facilitate controlled movement between the bone portions. When apparatus 2000 is used in conjunction with an barrel 2010, engaging member 2024 may slide with respect to transverse aperture 2012 (the sliding of which may be controlled by compression member 2026) and a shoulder of compression member 2026 may interact with flange 2022 to limit the depth of insertion of the fastening assembly 2004.

The fastening assembly used in conjunction with stabilizing structure 2002 may be any of the fastening assemblies illustrated in any of the Figures herein, or may be other types of fastening assemblies, and may function and be used in similar manners as the fastening assemblies described above in conjunction with intramedullary nails.

FIGS. 48-60 illustrate instrumentation used in accordance with one method for installing the apparatus 2000 shown in FIG. 47A, although other methods are possible and within the scope of the present invention.

FIG. 48 shows the stabilizing structure 2002 associated with a handle 2030. The handle 2030 can be attached to the stabilizing structure 2002 using a locking post screw 2032 connected to one of the apertures 2008 (such as shown in FIG. 48) or in another manner. Using the handle 2030, the stabilizing structure 2002 may be inserted percutaneously, keeping soft tissue damage to a minimum. Once inserted percutaneously, stabilizing structure 2002 may be secured to an outer surface of the bony anatomy using one or more screws or other fasteners passing through apertures 2008. In other embodiments, stabilizing structure 2002 can be secured to the bony anatomy using screws or other fasteners passing through apertures 2008 at any point during the installation of apparatus 2000.

As shown in FIG. 49, the handle 2030 may also receive a targeter 2034. The targeter 2034 shown in FIG. 49 includes an opening 2036 to permit the insertion of a drill sleeve 2038 (as shown in FIG. 50) as well as other apertures 2040 for receiving additional fixation tools, devices or other structures. In other embodiments, targeter 2034 is integral with handle 2030. In still other embodiments, targeter 2034 is not necessary, and drill sleeve 2038 may be positioned with respect to the stabilizing structure 2002 in another manner. For instance, in some embodiments, drill sleeve 2038 is connected to handle 2030 directly, or is formed integrally with handle 2030.

The drill sleeve 2038 shown in FIG. 50 extends through the opening 2036 in the targeter 2034 to approximately the transverse aperture 2006 extending through stabilizing structure 2002. As shown, the drill sleeve 2038 includes first and second tubular portions 2042 and 2044. Tubular portions 2042 and 2044 may receive a wide variety of tools, instruments, and other items.

For instance, FIGS. 51 and 52 illustrate the insertion of a guide pin sleeve 2046 into the first tubular portion 2042, which may be cannulated to receive a guide pin (not shown). The guide pin may be used to guide the movement of subsequent instrumentation or other items placed into one or both of the tubular portions 2042 and 2044.

FIGS. 53-54 illustrate the insertion of a compression member drill guide 2048 into the second tubular portion 2044 to guide the movement of one or more drills that will prepare a cavity in the bone for receiving the compression member 2026. Similar instrumentation may be used to prepare another (albeit overlapping in some embodiments) cavity for receiving the engaging member 2024. The same, or different, instrumentation may be used to prepare portions of the drilled cavities to receive the barrel 2010 as well. For instance, in some embodiments, there may be four drilling procedures: one to drill a cavity for receiving the compression member 2026, a second to drill a proximal portion of that cavity slightly larger to receive, in part, the barrel 2010, a third to drill a cavity for receiving the engaging member 2024, and a fourth to drill a proximal portion of that cavity slightly larger to receive, in part, the other part of the barrel 2010 not accounted for by the second drilling operation. The order and number of these drilling procedures are not necessarily important in all embodiments. In some embodiments, it may be desirable to insert an anti-rotation device 2050 (such as shown in FIG. 55) into one or both of the tubular portions 2042 and 2044 to prevent the bone portions from rotating with respect to one another during the drilling procedures.

After the cavity for the engaging member 2024 has been prepared, the engaging member 2024 may be inserted using an inserter, such as the inserter 2052 shown in FIG. 56. The inserter 2052 shown in FIG. 56 includes a long cylindrical body 2054 attached to a T-handle 2056. The inserter 2052 may be used to drive the engaging member 2024 into the prepared cavity, and also to rotate the engaging member 2024 to facilitate engaging the bone, such as the femoral head. In some embodiments, the inserter 2052 may be cannulated and include a rod extending along at least a portion of the length of the cannulation, with a threaded tip at its end. This threaded tip may interact with threads (not shown) inside the head of the engaging member 2024 to connect the inserter 2052 to the engaging member 2024. In other embodiments, power tools may be employed to help engage the engaging member 2024 with the bone.

After the engaging member 2024 is installed, as shown in FIGS. 57-60, the T-handle 2056 may be removed and the barrel 2010 may be slipped over the cylindrical body 2054 of the inserter 2052 and driven into place using another inserter 2058. The instrumentation may guide the barrel 2010 over the engaging member 2024 and into the transverse aperture 2006 of the stabilizing structure 2002. The ridge 2016, arm 2014 and indentations 2018 and 2020 discussed above may allow the barrel to be snapped into place in the transverse aperture 2006.

Subsequently, the compression member 2026 may be installed and adjusted (as discussed above for the intramedullary nail, or in other manners) and the various instrumentation may be removed to complete the installation.

In accordance with the above-described, or other, methodologies, an apparatus 2000 may be installed in the following manner. First, one or more incisions may be made into the patient proximal the relevant bony anatomy. Next, the handle 2030 (as assembled to stabilizing structure 2002, as shown in FIG. 48) may be used to position stabilizing structure 2002 proximate the relevant bony anatomy, such as the lateral side of the proximal femur. Next, the targeter 2034 may be assembled to the handle 2030 as shown in FIG. 49, although, in other embodiments, targeter 2034 may already have been assembled to handle 2030, or may not even be necessary. Subsequently, the drill sleeve 2038 may be inserted through targeter opening 2036 (although in other embodiments, drill sleeve 2038 may be associated directly with handle 2030 or may be associated with stabilizing structure 2002 in some other manner), as shown in FIG. 50.

As shown in FIGS. 51 and 52, a guide pin sleeve 2046 may be inserted into first tubular portion 2042. Next, a guide pin or wire may be inserted through a longitudinally extending aperture in guide pin sleeve 2046, and the guide pin or wire may engage a portion of the bony anatomy. In some embodiments, the axis of the guide pin may define the axis of the engaging member 2024, once the engaging member 2024 is installed. At this point, in some embodiments, fasteners may be installed through additional apertures 2008 to secure the stabilizing structure 2002 to the bony anatomy, although, in other embodiments, these fasteners may be installed at other points during the installation.

FIG. 53 shows the compression member drill guide 2048 being inserted into the second tubular portion 2044 of the drill sleeve 2038 next. An aperture extending through the compression member drill guide 2048 may receive a drill bit for preparing the bony anatomy to receive the compression member 2026. Subsequently, the compression member drill guide 2048 may be removed and a second drill bit may be guided through second tubular portion 2044 to prepare the bony anatomy to receive a portion of an barrel 2010. In other embodiments, both of these drilling operations may be accomplished using a single combination drill bit, such as a bit similar to the combination drill bit described below. As shown in FIG. 55, an anti-rotation device 2050 may be subsequently inserted into second tubular portion 2044 such that a distal portion of the device 2050 fits into the portion of the bony anatomy prepared for the compression member 2026 and a proximal portion of the device 2050 fits into the portion of the bony anatomy prepared to receive a portion of the barrel 2010.

Subsequently, the guide pin sleeve 2046 may be removed and one or more drill bits may be guided over the guide pin or wire through the first tubular portion 2042 to prepare the bony anatomy to receive the engaging member 2024 and other portions of the barrel 2010. In some embodiments, this step may be accomplished using a combination drill bit that includes two different outer diameters. In other embodiments, multiple drill bits may be employed.

Next, the inserter 2052 shown in FIG. 56 may be used to install the engaging member 2024 and barrel 2010, as described above and shown in FIGS. 56 through 60. Subsequently, the compression member 2026 may be installed. In some embodiments, the compression member 2026 may subsequently be used to compress the fracture, although in other embodiments, it may not be necessary or desirable to compress the fracture.

As those skilled in the art will appreciate, the particular embodiments of this invention described above and illustrated in the figures are provided for explaining the invention, and various alterations may be made in the structure and materials of the illustrated embodiments without departing from the spirit and scope of the invention as described above and in the following claims.

FIG. 61 shows an embodiment that includes an adjustable stop 2060 for limiting the sliding of fastening assembly 2004.

In some embodiments, the adjustable stop 2060 is at least partially inserted on the lateral side of the stabilizing structure 2002 through the transverse aperture 2006. In the embodiment shown, the adjustable stop 2060 is inserted into the distal circular portion of the transverse aperture 2006. In other embodiments, however, the adjustable stop 2060 could be located in the proximal circular portion of the transverse aperture 2006. In some embodiments the adjustable stop 2060 is located approximately behind the compression member 2026, but in others, it is located approximately behind the engaging member 2024.

In some embodiments the transverse aperture 2006 has a cooperation structure 2064, such as internal threading. In FIG. 62, the cooperation structure 2064 is located in the distal circular portion of the transverse aperture 2006, but in other embodiments, the cooperation structure 2064 is located in the proximal circular portion of the transverse aperture 2006. The adjustable stop 2060 may also have cooperation structure for cooperating with the cooperation structure 2064. For example, in FIGS. 62-64, the cooperation structure 2064 is a threaded portion, and the adjustable stop 2060 has external threads that cooperate with the threaded portion of the transverse aperture 2006. Alternative cooperating structures are also possible. FIGS. 65-81 schematically illustrate examples of other potential types of cooperation structures. For instance, in FIGS. 65 and 66, the cooperation structure 2064 is a slot, and the adjustable stop 2060 has a key that cooperates with the slot. In FIGS. 67 and 68, the cooperation structure 2064 is a set of ratchet teeth, and the adjustable stop 2060 has a set of ratchet teeth. In FIGS. 69-71, the cooperation structure 2064 is a tapered hole, and the adjustable stop 2060 has a cone shape that cooperates with the tapered hole. In FIGS. 72 and 73, the cooperation structure 2064 is at least one protrusion, and the adjustable stop 2060 has at least one indention to cooperate with the protrusion. In FIGS. 74 and 75, the cooperation structure 2064 is an indentation, and the adjustable stop 2060 has a ridge that cooperates with the indentation. In FIGS. 76 and 77, the cooperation structure 2064 is at least one groove, and the adjustable stop 2060 has a prong that cooperates with the at least one groove. In FIGS. 78 and 79, the cooperation structure 2064 is a set screw, and the adjustable stop 2060 has a structure to receive the set screw.

One of ordinary skill in the art would know that switching the cooperation structure 2064 and the structure on the adjustable stop 2060 would not materially affect the properties of the invention. For example, with respect to FIGS. 65 and 66, one of ordinary skill in the art may design the cooperation structure 2064 to be a key, and design the structure on the adjustable stop 2060 to be a slot. As another example, with respect to FIGS. 72 and 73, one of ordinary skill in the art may design the cooperation structure 2064 to be an indention, and design the structure on the adjustable stop 2060 to be a protrusion.

FIGS. 80 and 81 illustrate an embodiment of an adjustable stop 2060 wherein, rather than adjusting the position of the stop in the transverse aperture 2006, the length of the adjustable stop itself (or portions thereof) may be adjusted. In this embodiment, if it is desired to reduce the distance that the fastening assembly 2004 may slide, then a portion of the adjustable stop 2060 is adjusted to result in an increased total length of the adjustable stop 2060. If it is desired to increase the distance that the fastening assembly 2004 may slide, then a portion of the adjustable stop 2060 is adjusted to result in a decreased total length of the adjustable stop 2060.

As can be seen from FIGS. 82A through 82C, the adjustable stop 2060 may be adjusted to position it more medially or more laterally with respect to the transverse aperture. As the adjustable stop 2060 moves in the medial direction, it moves towards the compression member 2026, thereby minimizing the distance that the compression member 2026 may slide in the lateral direction. In FIG. 82A, the dimension l represents the distance that the compression member 2026 may slide in the lateral direction. In FIG. 82A the adjustable stop 2060 is partially inserted and occupies approximately half of the dimension l. Therefore, the compression member 2026 is prohibited by the adjustable stop 2060 from sliding throughout the entire dimension l. The adjustable stop 2060 acts as a stop to limit the distance that the compression member 2026 may slide in the lateral direction. In FIG. 82B, the adjustable stop 2060 is in the same position as in FIG. 82A; however, the compression member 2026 has slid in the lateral direction and has been stopped by the adjustable stop 2060. In FIG. 82C, the adjustable stop 2060 is fully inserted and the compression member 2026 is generally prohibited from sliding throughout dimension l at all.

Embodiments of the invention that include an adjustable stop 2060 may beneficially limit soft tissue irritation on the lateral side of the stabilizing structure by preventing portions of the fastening assembly 2004 from extending laterally outside of the transverse aperture 2006. In embodiments without an adjustable stop 2060, the compression member 2026 may slide in the lateral direction and protrude beyond the stabilizing structure 2002. Soft tissue located on the lateral side of the stabilizing structure 2002 may be irritated or harmed by the protrusion of the compression member 2026.

In some embodiments, the compression member 2026 and the engaging member 2024 move within the transverse aperture 2006 as a unit. Therefore, when the compression member 2026 is prohibited from sliding, the engaging member 2024 is prohibited from sliding as well. This controlled sliding results in controlled compression of the first and second bone portions. As discussed above, the engaging member 2024 is engaged with the second bone portion. Therefore, when the sliding of the engaging member 2024 is controlled, the compression of the bone portions is also controlled. More compression of the first and second bone portions may be realized when the fastening assembly 2004 is allowed maximum sliding within the transverse aperture, such as shown in FIG. 82A. Likewise, less compression of the first and second bone portions can be realized when the fastening assembly 2004 is allowed minimal sliding within the transverse aperture, such as shown in FIG. 82C.

The controlled sliding, and therefore compression of the bone portions, may help to prevent excessive compression between the bone portions. Oftentimes the bone adjacent to the fracture is weak and is prone to damage when exposed to excessive compression. In some cases, excessive compression may cause the femoral head to be compressed all the way into the trochanteric region of the femur. The adjustable stop 2060 limits the distance that the fastening assembly 2004—and consequently the femoral head—is free to move in the lateral direction towards the trochanteric region of the femur, and therefore helps to reduce excessive compression between the weak bone adjacent to the fracture site.

In some embodiments, the adjustable stop 2060 may also allow the surgeon to select the amount of lateral sliding, and thereby compression of the bone portions, that he/she desires. In some embodiments the pitch of the threads on the adjustable stop 2060 and in the transverse aperture (or other configuration of the cooperation structure 2064) may be designed to provide a set amount of adjustment per rotation of the adjustable stop 2060. For example, if it is desired to produce an incremental change of approximately 1 mm of lateral sliding for one adjustment of the adjustable stop 2060, then a thread pitch of approximately 1 mm is selected for the cooperation structure 2064 and for the threads on the adjustable stop 2060. Subsequent adjustments of the adjustable stop 2060 result in subsequent changes of approximately 1 mm of lateral sliding. On the other hand, if it is desired to produce an incremental change of approximately 2 mm of lateral sliding for one adjustment of the adjustable stop 2060, then a thread pitch of approximately 2 mm is selected for the cooperation structure 2064 and for the threads on the adjustable stop 2060. It should be recognized that the surgeon may choose to adjust the adjustable stop 2060 through incremental adjustments; in other words, the surgeon may adjust the adjustable stop 2060 by only one half of a rotation, or two thirds of a rotation.

The adjustable stop 2060 may have some structure on at least one end to enable a surgeon to adjust the adjustable stop 2060 relative to the stabilizing structure 2002. In the embodiment shown in FIG. 63, for example, the structure is an indention that receives a tool for turning the adjustable stop 2060. In some embodiments the structure is a hex-shaped indention that may receive a hex shaped tool such as a hex driver. In some embodiments the adjustable stop 2060 also has a threaded hole, which may facilitate securing the hex driver to the adjustable stop 2060. U.S. Pat. No. 6,565,573, filed on Apr. 16, 2001, describes such a structure.

In the embodiment shown in FIG. 64, one end of the adjustable stop 2060 is chamfered. The chamfered end may help the surgeon to smoothly insert the adjustable stop 2060 into the transverse aperture 2006. In other embodiments, such as in FIGS. 65-81, the adjustable stop 2060 does not have a chamfered end.

FIG. 64 also shows that the adjustable stop 2060 may include one or more deformable inserts 2062 positioned around the perimeter of the stop. In some embodiments, the deformable insert 2062 may be located at any height along the axis of the adjustable stop 2060. In the embodiment of FIG. 64, the deformable insert 2062 has a circular cross section, but in other embodiments the deformable insert 2062 may have other shapes. For example, in FIG. 65 the deformable insert 2062 is shaped like a square, and in FIG. 67 the deformable insert 2062 is shaped like a triangle. The surface of the deformable insert 2062 may be substantially flat, or it may have texture such as ridges, indentions, protrusions, or cross-hatching. The deformable insert 2062 may be made of polymer, polymeric material, ultra-high molecular weight polyethylene, polyurethane, tephlon, or any other biocompatible implant grade material that can deform. The standard known as ISO 10993 lists types of material that may be considered biocompatible implant grade materials.

In some embodiments, when the adjustable stop 2060 is inserted into the transverse aperture 2006, the deformable insert 2062 interacts with the cooperation structure 2064 (such as meshing with the threads) in order to at least partially limit movement of the adjustable stop 2060 inside of the transverse aperture 2006. In the embodiment shown in FIG. 64, the adjustable stop 2060 is threaded and the deformable insert 2062 is flat. The deformable insert 2062 extends outwardly to the major diameter of the threads of the adjustable stop 2060. In the embodiments shown in FIGS. 65-81, the deformable insert 2062 may extend slightly beyond the surface of the adjustable stop 2060, or may also be flush with the surface of the adjustable stop 2060. When the adjustable stop 2060 is inserted into the transverse aperture 2006, the deformable insert 2062 deforms against the cooperation structure 2064. When deformed, the deformable insert 2062 frictionally engages the cooperation structure 2064. The friction between the deformable insert 2062 and the cooperation structure 2064 will tend to maintain the positioning of the adjustable stop 2060 within the transverse aperture 2006.

Alternatively, in some embodiments the deformable insert 2062 is inside of the barrel 2010. For example, the deformable insert 2062 may be located inside of the barrel 2010 on the cooperation structure 2064. If the cooperation structure 2064 is a set of threads, then the deformable insert 2062 may be a flat insert that extends outwardly to the major diameter of the threads as described in FIG. 64. The deformable insert 2062 that is located inside the barrel 2010 may also take on the embodiments as shown in FIG. 65-81. In still other embodiments, there may be deformable insert(s) 2062 on both the adjustable stop 2060 and inside the barrel 2010.

FIGS. 83-87 show another embodiment of the present invention in which the stabilizing structure 2002 includes structure for cooperating with various types of attachments, such that attachments may be easily connected to the stabilizing structure 2002, even after it has been implanted into a patient (including fastened to a bone). As shown best in FIGS. 83 and 85, the stabilizing structure 2002 may include structure shown generally at 2070 (such as depressions formed in the stabilizing structure 2002 and flanges extending outwardly from other portions of the stabilizing structure 2002). The structure 2070 may cooperate with corresponding structure 2074 on various types of attachments (such as the handle 2072 shown in FIG. 86) to at least partially and temporarily secure and orient the attachment with respect to the stabilizing structure 2002. Such attachment structure 2070 may be beneficial over previous implants, which may require that items be secured to the implant before implantation, limiting the flexibility a surgeon has for performing a surgical procedure. Attachments that may interact with the attachment structure 2070 may include, among other things, guide handles, targeting devices, drill guides, insertion tools, other types of guides, or other instruments or desirable attachments. In some embodiments, stabilizing structure 2002 may include a threaded aperture (such as the threaded aperture 2008 shown in FIG. 83), which may receive a threaded fastener of one of the attachments to help further secure the attachment to the stabilizing structure 2002.

In some embodiments, the structure 2070 may also help guide the attachment onto the stabilizing structure 2002. For instance, as shown in FIGS. 85 and 86, the structures 2070, 2074 on the stabilizing structure 2002 and the handle 2072 that help attach one to the other may define elongated flanges and grooves, such that the flange is guided into the groove as the attachment 2072 is secured to the stabilizing structure 2002. In some embodiments, such as embodiments used in minimally invasive surgery, such guiding action may be particularly beneficial. FIG. 87 illustrates an attachment 2072 being attached to a stabilizing structure 2002.

In the embodiment of FIG. 83, the attachment structures 2070 are symmetric across the longitudinal axis of the stabilizing structure 2002. In other embodiments, however, structure may be asymmetric. In other embodiments, the structure 2070, 2074 on the stabilizing structure 2002 and attachment 2072 may have other geometries other than those specifically shown in the Figures.

FIGS. 88-90 show one embodiment wherein an engaging member 3024 has at least one keyed structure 3025 that cooperates with a second keyed structure 3011 that is located inside a transverse aperture of a barrel 2010. The barrel 3011 may be either modular or integral with the stabilizing structure. The keyed structure 3025 may be located at any location along the outer surface of the engaging member 3024. Additionally, the keyed structure 3025 may be any length. There may be only one keyed structure 3025, or there may be a plurality of keyed structures 3025. In the embodiments shown in the figures, the keyed structure 3025 is a substantially planar section located on the outer surface of the engaging member 3024. In general the keyed structure 3025 may include other structure, such as the structure described in FIGS. 65-79, including keys, slots, ratchet teeth, cone shapes, protrusions and indentions, ridges, grooves, ridges, and set screws.

In some embodiments, the keyed structure 3025 on the engaging member 3024 cooperates with a second keyed structure 3011 associated with a modular barrel 3010 and/or integral barrel 3010. The second keyed structure 3011 cooperates with the first keyed structure 3025 to prohibit or limit the engaging member 3024 from moving within the barrel 3010. For example, in the figures the keyed structures 3025, 3011 are substantially planar and prohibit the engaging member from rotating. The keyed structures 3011, 3025 additionally help guide the engaging member 3024 into the barrel 3010 and help ensure proper alignment. 

1. Apparatus for treating bone fractures comprising a first bone portion and a second bone portion, the apparatus comprising: (a) a stabilizing structure for connection to an outer surface of the first bone portion, the stabilizing structure comprising a barrel defining a transverse aperture; (b) a fastening assembly comprising an engaging member and a compression member, (i) the engaging member comprising a channel and a first cooperation structure to cooperate with the compression member, and wherein the compression member nests partially within the channel of the engaging member; (ii) wherein the engaging member and the compression member at least partially extend through the transverse aperture of the barrel, and the engaging member and the compression member are adapted to slide within the transverse aperture as a unit; (iii) wherein the engaging member engages the second bone portion and the compression member contacts the second bone portion; and (c) an adjustable stop at least partially positioned in the transverse aperture such that a portion of the adjustable stop can contact a portion of the fastening assembly to limit the sliding of the fastening assembly, wherein the position of the adjustable stop is adjustable to alter the limitation on the sliding of the fastening assembly.
 2. Apparatus according to claim 1 wherein at least a portion of the transverse aperture has a second cooperation structure, and wherein the adjustable stop cooperates with the second cooperation structure.
 3. Apparatus according to claim 2 in which the second cooperation structure includes at least one of a key, a set of ratchet teeth, a threaded portion, a cross hair screw, a taper, protrusions, indentions, prongs, grooves, or ridges.
 4. Apparatus according to claim 2 wherein the second cooperation structure is a threaded portion with a pitch, and adjustment of the adjustable stop alters the limitation on the sliding of the fastening assembly by an amount that corresponds to the pitch on the threaded portion.
 5. Apparatus according to claim 2, wherein the adjustable stop further comprises at least one deformable insert that frictionally interacts with a portion of the second cooperation structure to at least partially limit movement of the adjustable stop in the transverse aperture.
 6. Apparatus according to claim 5, wherein the at least one deformable insert is made of polymeric material, ultra-high molecular weight polyethylene, polyurethane, tephlon, or any other biocompatible implant grade material that can deform.
 7. Apparatus according to claim 1 in which the stabilizing structure is at least one of a compression plate or a periarticular plate.
 8. Apparatus according to claim 1 wherein when the compression member is adjusted relative to the engaging member, the compression member contacts and interacts with a portion of the stabilizing structure and the first cooperation structure to thereby cause compression of the first and second bone portions relative to each other.
 9. Apparatus according to claim 1 wherein when the compression member is adjusted relative to the engaging member, the compression member contacts and interacts with a portion of the stabilizing structure and the first cooperation structure to control sliding of the engaging member and the compression member in the transverse aperture.
 10. Apparatus according to claim 1 in which the transverse aperture is asymmetrical in cross section and includes a first portion adapted to receive at least part of the engaging member and a second portion adapted to receive at least part of the compression member.
 11. A process for repairing bone, comprising: (a) providing a device for treating bone fractures, comprising: (i) a stabilizing structure adapted to be connected to an outer surface of a first bone portion and defining a transverse aperture; (ii) a fastening assembly adapted to slide within the transverse aperture and comprising a first and second members, wherein one of the first and second members at least partially nests within a channel formed on the other of the first and second members; and (iii) an adjustable stop that at least partially extends through the transverse aperture; (b) preparing at least one opening in first and second bone portions corresponding in location and orientation to a desired location and orientation of the first member and second member; (c) engaging the first member with the second bone portion; (d) connecting the stabilizing structure to the first bone portion; (e) passing the first member through the transverse aperture; (f) passing the second member through the transverse aperture; (g) adjusting the second member as the second member bears against a surface in the transverse aperture and draws the first member in a lateral direction; (h) at least partially inserting the adjustable stop into the transverse aperture and adjusting the adjustable stop to thereby adjust a limitation on the maximum amount of sliding of the fastening assembly in a lateral direction.
 12. The process according to claim 11, whereby movement of the first member in the lateral direction compresses the first bone portion and the second bone portion together.
 13. The process according to claim 11, wherein rotating the adjustable stop in a first direction reduces the maximum amount of sliding of the fastening assembly in the lateral direction.
 14. The process according to claim 13, wherein rotating the adjustable stop in a second direction increases the maximum amount of sliding of the fastening assembly in the lateral direction.
 15. Apparatus for treating fractures of the proximal femur comprising a first bone portion and a second bone portion, the apparatus comprising: (a) a bone plate for connection to an outer surface of the first bone portion, the bone plate comprising a barrel defining a transverse aperture; (b) a fastening assembly comprising an engaging member and a compression member, (i) the engaging member comprising a channel and a first threaded portion to cooperate with a second threaded portion on the compression member, and wherein the compression member nests partially within the channel of the engaging member; (ii) wherein the fastening assembly at least partially extends through the second transverse aperture of the barrel, and the fastening assembly is adapted to slide within the second transverse aperture as a unit; (iii) wherein the engaging member engages the second bone portion and the compression member contacts the second bone portion; and (c) an adjustable stop comprising at least one deformable insert, (i) wherein the adjustable stop is at least partially positioned in the transverse aperture such that a portion of the adjustable stop can contact a portion of the fastening assembly to limit the sliding of the fastening assembly; (ii) wherein the position of the adjustable stop is adjustable to alter the limitation on the sliding of the fastening assembly; (iii) wherein the at least one deformable insert frictionally interacts with a portion of the transverse aperture to at least partially limit movement of the adjustable stop in the transverse aperture.
 16. Apparatus as in claim 15, wherein the transverse aperture further comprises a third threaded portion with a pitch of 1 mm, and adjustment of the adjustable stop alters the limitation on the sliding of the fastening assembly by 1 mm. 